110531 25 FRM IncAnnuityDirDep - Fidelity Investments

Income Annuity Direct Deposit Form

Use this form to automatically transfer income payments from your Fidelity1 Income Annuity directly to your bank account or Fidelity Brokerage or Mutual Fund account. Be sure to complete all sections and read carefully before signing. If you have any questions about how to fill out this form, please call the Annuity Service Center at 800-634-9361, Monday through Friday, 8 a.m. to 8 p.m. Eastern time. Faxes not accepted.

1 CONTRACT OWNER INFORMATION (This section to be completed by the annuity owner.)

Contract Number Owner's First Name Joint Owner's First Name

-

-

Phone Number

Owner's Last Name/Trust Name

Joint Owner's Last Name

-

-

Owner's Social Security/Tax ID Number

-

-

Joint Owner's Social Security Number

2 TRANSFER INSTRUCTIONS (Complete this section to indicate where your income payment should be directly deposited.)

Option 1: Transfer the proceeds to my Fidelity Nonretirement Brokerage or Mutual Fund account. Fidelity Account Guidelines: ? One common Owner name must appear on both your Fidelity Account and Annuity.

Account Type: Fidelity Brokerage Account

Account Number

Fidelity Mutual Fund Account

-

Account Number

Mutual Fund Name _________________________________________________ Mutual Fund Number

Fund Number

Option 2: Send the proceeds directly to my bank account. Bank Account Guidelines: ? For verification of checking accounts, attach a voided or canceled check imprinted with your name (not a checking deposit slip, please).

Business accounts are not eligible. ? For verification of savings accounts, attach a copy of a bank statement or a deposit slip with your name and account number. Passbook

savings accounts are not eligible. ? Your account must be with a commercial bank, savings and loan, or credit union that is a member of the Automatic Clearing House (ACH).

If you are unsure, call your bank or credit union. ? One common Owner name must appear on both your bank account and Annuity. ? Allow at least 10 business days for banking instructions to become active after we receive the form.

Account Type: Checking Account (please attach a voided check below)

Savings Account (please attach a copy of your bank statement) Staple voided check here.

VOID

Please continue

1 Fidelity refers to Fidelity Investments Life Insurance Company and, in New York, Empire Fidelity Investments Life Insurance Company?, New York, N.Y.

010930001

3 AUTHORIZED SIGNATURE(S) (This section to be completed and signed by all owners)

I (We) authorize that all the above is true.

I (We) authorize Fidelity Investments Life Insurance Company and, for New York residents, Empire Fidelity Investments Life Insurance Company? to deposit annuity income directly to my (our) bank account or my Fidelity Brokerage or Mutual Fund account as indicated on this form. I authorize and request the bank named above to accept such entries from Fidelity, and to credit my account at that bank in accordance with these entries. I agree to direct my executors, administrators, or assignees to refund to Fidelity Investments Life Insurance Company and, for New York residents, Empire Fidelity Investments Life Insurance Company? any payments that are made following my death so that they may be redistributed to my beneficiary(ies), if applicable. I also agree to any necessary adjustments for deposits made in error. If I wish to end or change this authorization, I will notify the Fidelity Annuity Service Center in writing.

X

SIGNATURE OF OWNER

DATE

X

SIGNATURE OF JOINT OWNER (IF APPLICABLE)

DATE

Regular Mail Except NY

Annuity Service Center PO Box 770001 Cincinnati, OH 45277-0050

Regular Mail NY only

Annuity Service Center PO Box 770001 Cincinnati, OH 45277-0051

Overnight Mail

Fidelity Investments KC2Q 100 Crosby Parkway Covington, KY 41015

397477.3.0

Fidelity Brokerage Services LLC, Member NYSE, SIPC

1.900215.101

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